His diagnosis is right, but the treatment is all wrong

03.11.2016

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Dr. Sandeep Jauhar, a cardiologist, believes with good reason that many physicians have become “like everybody else: insecure, discontented and anxious about the future.”

In a widely-circulated column in the Wall Street Journal, “Why Doctors Are Sick of Their Profession,” he explains how medicine has become simply a job, not a calling, for many physicians; how their pay has declined, how the majority now say they wouldn’t advise their children to enter the medical profession, and how this malaise can’t be good for patients.

Dr. Jauhar gets it right in many ways, but the solutions he recommends miss their mark completely.

I was 100% in accord with Dr. Jauhar when he argued that “there are many measures of success in medicine: income, of course, but also creating attachments with patients, making a difference in their lives and providing good care while responsibly managing limited resources.”

The next paragraph, though, I read with astonishment. Does Dr. Jauhar really believe that publicizing surgeons’ mortality rates or physicians’ readmission rates can be “incentive schemes” that will reduce physician burnout? Does he seriously think that “giving rewards for patient satisfaction” will put the joy back into practicing medicine?

If so, I’m afraid he doesn’t understand the problem that he set out to solve.

The truth behind “quality” metrics

There is no question that some physicians are inherently more talented, more dedicated, and more skilled than others. In every hospital, if you speak to staff members privately, they’ll tell you which surgeon to see for a slipped disk, a kidney transplant, or breast cancer. They’ll tell you which of the anesthesiologists they trust most, and which cardiologist they would recommend to someone with chest pain. But none of these recommendations are based on simplistic metrics like readmission rates or even mortality rates. They are based on observations over time of the physicians’ ability, integrity, and conscientiousness–all of which are tough to quantify.

Let’s take, for example, a common operation such as laparoscopic cholecystectomy: removal of the gallbladder using cameras and instruments inserted through small incisions in the abdomen. This is a procedure which most general surgeons perform often, with few complications.

When complications occur, there are almost always factors involved other than surgical error. Patients with diabetes are more likely to develop wound infections, for instance. Surgery on patients who have had prior abdominal operations may take longer and could cause bleeding or damage to other internal organs because of scar tissue. Morbid obesity and advanced age are risk factors too.

The surgeon whose mortality rates are higher, or whose patients are more likely to be readmitted to the hospital, may be dealing with a much different patient population from the surgeon with the lowest rates. An inner-city hospital may admit more patients as emergency cases, in more advanced stages of disease.

It’s difficult for statistics to reflect accurately the dramatic differences among patients that affect surgical outcome. A noncompliant patient who doesn’t fill prescriptions and follow instructions is more likely to have problems, independent of the experience and skill of the surgeon. Trying to distinguish among surgeons with “outcomes data” will only result in more surgeons refusing to operate on high-risk patients.

Emphasizing 30-day readmission rates as a quality measure puts pressure on hospitals too. CMS now plans to link hospital payment to readmission rates and hospital-acquired complication rates. Community hospitals inevitably will feel pressure to funnel complicated, frail, or high-risk patients to the nearest major medical center which can’t bar them from the ER.

In my own line of work, anesthesiology, I often take care of patients who need chest surgery. They have serious illnesses such as lung cancer, emphysema, and ALS–the bucket-challenge disease. These high-risk patients don’t all have good outcomes, though I like to think that my management of their anesthesia care helps most of them return safely home.

My scores are fine on the meaningless “quality” metrics that the Joint Commission and CMS use to rate anesthesiology performance, despite their scant relation to clinical excellence.

But the best measure of whether or not I’m a good anesthesiologist isn’t either my outcomes data or my “quality” scores. It’s the fact that surgeons and OR staff members at my hospital, who watch me work every day, often request me when they or their family members need anesthesia. That’s a measure you won’t find in any report.

I can’t think of a worse way to address physician burnout than to publicize flawed “quality” or outcomes data that would unfairly pit physicians against one another. Dr. Jauhar’s further recommendation to link doctors’ pay to health outcomes (“pay for performance“) would only make matters worse.

The perils of patient satisfaction scores

Dr. Jauhar writes that his hospital sends quarterly reports to physicians, telling them how their patients rate them on different points such as communications skills and time spent with them. I’m guessing that his reports must be good, or he wouldn’t consider patient satisfaction scores to be an incentive that could reduce physician malaise.

I’m also guessing that Dr. Jauhar’s colleagues in emergency medicine and primary care might feel differently. Those physicians are under daily pressure to give narcotics to any patient who complains of pain, to prescribe antibiotics to patients who don’t need them, and to order expensive tests like CT scans at the slightest indication. To do otherwise is to risk poor patient satisfaction scores.

The Atlantic published an article: “When Physicians’ Careers Suffer Because They Refuse to Prescribe Narcotics.” It highlighted the fallacy in satisfaction scores, noting that “patient perceptions may prove downright misleading.” Patients often visit multiple emergency rooms and doctors’ offices asking for narcotics, and “the problem of prescription drug abuse and drug-seeking behavior is abetted by a robust and growing black market for prescription medications.” They’ll be angry if their narcotic requests are denied. Still, physicians are at risk for being hired or fired on the basis of patient satisfaction data, without critical review of the source.

Do high patient satisfaction scores correlate with better health? Or higher quality care? So far, the answer is no. A study of hospitalized patients showed that many patients prefer “shared decision-making” with their physicians, but it results in longer inpatient hospital stays and 6 percent higher total hospitalization costs.

A prospective study of over 50,000 clinic patients showed that the 25% who were most satisfied with their care had higher odds of inpatient admission, greater total expenditures, greater prescription drug expenditures, and–perhaps most surprising–higher mortality. I can easily see how that could happen in the treatment of pain after surgery. If you gave every patient enough morphine or Demerol, you wouldn’t hear complaints of pain. But the patients would be sleepy, wouldn’t want to get out of bed, and would run a higher risk of breathing problems and blood clots due to inactivity.

Dr. Jauhar concludes that the solution to satisfaction as a physician is to settle for less. He looks to medical students, who are “not so weighed down by great expectations”, to be the physicians of the future who won’t mind less money and prestige.

But here is where Dr. Jauhar misses the heart of the issue. Most physicians didn’t go into medicine thinking to make a fortune–we leave that to the entrepreneurs and investment bankers. Most of us never expected to be treated like gods, with the possible (tongue-in-cheek) exception of our colleagues in cardiac surgery and neurosurgery.

We did expect, though, to have a certain amount of autonomy in our daily working lives. We expected to want to come to work every day and take the best possible care of our patients. We expected to have our education and opinions valued and respected, not second-guessed at every step by bureaucrats with clipboards.

Here is what I see as the downhill slide of 21st century medicine:

1. The surge of uncritical belief in “evidence-based medicine” has led to rigid algorithms–cookbook recipes, really–for patient care. Experienced physicians know these algorithms are often a poor fit for patients with multiple medical problems, and must be ignored or subverted for the good of the patient. At the same time, the physician may face criticism or sanctions for not following protocol.

2. Bureaucrats and regulators seem convinced that if only we can produce enough care protocols, we can cut out physicians altogether and save money by having advanced practice nurses take care of everyone. They encourage the devaluation of physician education and expertise.

3. The unchecked power of regulatory agencies–including CMS and the Joint Commission–is growing, while their reason for being is the constant creation of new rules that get pettier by the day. These proliferating rules have become a dangerous distraction to physicians and nurses, and take time away from their patients.

Where to go from here?

It’s helpful to keep a few basic principles in mind.

Fee-for-service pay isn’t the chief culprit. The best physicians stay busy because they have respect and referrals from their peers. As they develop a base of satisfied patients and colleagues who recognize clinical excellence, they achieve financial success and have no wish to perform unnecessary procedures. Price-fixing of physician services by third-party payers is the root cause of financial pressure to increase the number of services provided.

Limited provider networks benefit only insurers and the government. They destroy long-standing patient-physician relationships, and prevent physicians from referring patients to other physicians whose work they know and trust.

Encouraging the medical students of today to settle for less isn’t the way to get the best and brightest to become the physicians of tomorrow. As a society, we need to push back hard against today’s flawed rules, laws, algorithms and metrics that promote mediocrity and standardization, and provide all the wrong incentives in healthcare. That’s the only way that all of us–physicians and patients–will be able to enjoy the experience of individualized, personal patient care.

After all, the “human moments”, as Dr. Jauhar rightly points out, are the best part of medicine.

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